Mailed outreach and facilitated test ordering to promote cholesterol screening in community health centers: A randomized trial.

RATIONALE, AIMS, AND OBJECTIVES: Lipid screening is central to cardiovascular risk assessment. We sought to determine whether a simple mailed outreach message and facilitated test ordering increase cholesterol screening among federally qualified community health center patients with no recent cholesterol screening test performed. METHODS: Using a patient-randomized controlled trial, we examined the effects of delivering a simple mailed outreach intervention promoting cholesterol testing and facilitated test ordering (without requiring an office visit). Participants were adult patients 50 to 75 years old, with no diagnosed cardiovascular disease or diabetes, and no cholesterol test within 5 years who had received care from community health centers in Illinois and Arizona. The intervention took place in 2014 and was powered to detect a 10% increase in screening due to the intervention. RESULTS: Participants' (n = 480) mean age was 57.5 years, 51.0% were male, and 43.8% were smokers. There was no significant difference between groups in the primary study outcome-completion of total cholesterol and high-density lipoprotein cholesterol tests or complete lipid panel within 3 months; 32 participants (13.3%) in intervention group versus 26 (10.8%) in control group met the primary outcome, with absolute difference of 2.5 percentage points (95% confidence interval -6.6 to 11.6). CONCLUSIONS: This outreach intervention promoting cholesterol screening was ineffective. Interventions that attempt to minimize barriers to cholesterol screening on multiple fronts and that are more compelling to patients are needed.

Individualized Risk Communication and Outreach for Primary Cardiovascular Disease Prevention in Community Health Centers: Randomized Trial.

BACKGROUND: Many eligible primary cardiovascular disease prevention candidates are not treated with statins. Electronic health record data can identify patients with increased cardiovascular disease risk. METHODS AND RESULTS: We performed a pragmatic randomized controlled trial at community health centers in 2 states. Participants were men aged ≥35 years and women ≥45 years, without cardiovascular disease or diabetes mellitus, and with a 10-year risk of coronary heart disease of at least 10%. The intervention group received telephone and mailed outreach, individualized based on patients' cardiovascular disease risk and uncontrolled risk factors, provided by lay health workers. Main outcomes included: documented discussion of medication treatment for cholesterol with a primary care clinician, receipt of statin prescription within 6 months, and low-density lipoprotein (LDL)-cholesterol repeated and at least 30 mg/dL lower than baseline within 1 year. Six hundred forty-six participants (328 and 318 in the intervention and control groups, respectively) were included. At 6 months, 26.8% of intervention and 11.6% of control patients had discussed cholesterol treatment with a primary care clinician (odds ratio, 2.79; [95% confidence interval, 2.25-3.46]). Statin prescribing occurred for 10.1% in the intervention group and 6.0% in the control group (odds ratio, 1.76; [95% confidence interval, 0.90-3.45]). The cholesterol outcome did not differ, and the majority of patients did not repeat lipid levels during follow-up. CONCLUSIONS: Risk communication and lay outreach increased cholesterol treatment discussions with primary care clinicians. However, most discussions did not result in statin prescribing. For outreach to be successful, it should be combined with interventions to encourage clinicians to follow contemporary risk-based cholesterol treatment guidelines. CLINICAL TRIAL REGISTRATION: URL: http://www.clincialtrials.gov. Unique identifier: NCT01610609.

Colorectal Cancer Screening Rates at Community Health Centers that Use Electronic Health Records: A Cross Sectional Study.

BACKGROUND: This study was conducted to validate use of electronic health record (EHR) data for measuring colorectal cancer (CRC) screening rates at community health centers (CHCs). METHODS: Electronic health records were queried to assess screening via colonoscopy, flexible sigmoidoscopy, or fecal occult blood testing (FOBT) in 2011. RESULTS: Multiple iterations were required to maximize query accuracy. Manual chart reviews, stratified by screening modality, confirmed query results for 112 of 113 (99.1%) reviewed colonoscopies, 110 of 110 (100%) reviewed FOBTs, and 111 of 120 (92.5%) unscreened patients. At participating CHCs, CRC screening rates ranged from 9.7% to 67.2% (median, 30.6%). Adherence to annual FOBT ranged from 3.3% to 59.0% (median, 18.6%). Most screening was done by colonoscopy. CONCLUSIONS: Colorectal cancer screening varies substantially across CHCs. Electronic health record data can validly measure CRC screening, but repeated assessments of programming accuracy are required. Community health centers may need support to measure quality using EHR data and increase screening.

Colorectal cancer screening at community health centers: A survey of clinicians' attitudes, practices, and perceived barriers.

OBJECTIVE: Colorectal cancer (CRC) screening rates remain lower among some racial/ethnic groups and individuals with low income or educational attainment who are often cared for within community health centers (CHCs). We surveyed clinicians in a network of CHCs to understand their attitudes, practice patterns, and perceived barriers to CRC screening. METHODS: A clinician survey was conducted in 2013 within the Community Health Applied Research Network (CHARN). RESULTS: 180 clinicians completed the survey (47.9% response rate). Participants had an average of 11.5 (SD: 9.8) years in practice, 62% were female, and 57% were physicians. The majority of respondents somewhat agreed (30.2%) or strongly agreed (57.5%) that colonoscopy was the best screening test. However, only 15.8% of respondents strongly agreed and 32.2% somewhat agreed that colonoscopy was readily available for their patients. Fecal immunochemical testing (FIT), a type of fecal occult blood test (FOBT), was viewed less favorably; 24.6% rated FIT as very effective. CONCLUSIONS: Although there are no data showing that screening colonoscopy is superior to FIT, CHC clinicians believe colonoscopy is the best CRC screening test for their patients, despite the high prevalence of financial barriers to colonoscopy. These attitudes could be due to lack of knowledge about the evidence supporting long-term benefits of fecal occult blood testing (FOBT), lack of awareness about the improved test characteristics of FIT compared to older guaiac-based FOBT, or the absence of systems to ensure adherence to regular FOBT screening. Interventions to improve CRC screening at CHCs must address clinicians' negative attitudes towards FIT.

A model for evaluating the activities of a coalition-based policy action group: the case of Hermosa Vida.

Scholars and clinicians are increasingly recognizing the complexity of social contexts of health and the need for multifunctioning approaches to health care problems including community- and policy-level strategies. Barriers to change in health care policy can sometimes be attributed to the actions of advocacy coalitions who operate from a limited view of "policy change." Advocates have a tendency to pressure stakeholders to mandate laws as a final resolution of a movement, often leading to failure or, worse, stigmatizing of issues. A more inclusive focus on health policy change as an ongoing process increases the efficacy of advocacy and outcomes measurement. This article presents a tool for policy action that coalition members developed through the implementation of a 3-year grant to improve the safety net for preventing childhood obesity. Scholars and policy makers developed the Policy Coalition Evaluation Tool with the intent to create a model to guide and measure efforts and outcomes of a local community-based policy coalition. The authors suggest using community-based participatory research approaches for developing a coalition-specific Policy Coalition Evaluation Tool to increase the effectiveness of advocacy groups and the documentation of coalition activities over time.

A call for further research on the impact of state-level immigration policies on public health.

Arizona's Support Our Law Enforcement and Safe Neighborhoods Act, signed into law in April 2010, is already adversely affecting public health in the state. Our findings from a study on childhood obesity in Flagstaff suggest that the law changed health-seeking behaviors of residents of a predominantly Latino neighborhood by increasing fear, limiting residents' mobility, and diminishing trust of officials. These changes could exacerbate barriers to healthy living, limit access to care, and affect the overall safety of the neighborhood. Documentation of the on-the-ground impact of Arizona's law and similar state-level immigration policies is urgently needed. To inform effective policymaking, such research must be community engaged and include safety measures beyond the usual protocols.

Morinda citrifolia (noni) reduces cancer risk in current smokers by decreasing aromatic DNA adducts.

Quantitative determination of aromatic DNA adducts in peripheral blood lymphocytes (PBLs) of current smokers is an useful surrogate biomarker for the evaluation of environmental carcinogen exposure or chemopreventive intervention. In this study, we examined the impact of Tahitian Noni Juice (TNJ) on the aromatic DNA adducts of PBLs, before and after a 1-mo intervention, using (32)P postlabeling assay. Of 283 enrolled, 203 smokers completed the trial. Aromatic DNA adducts levels in all participants were significantly reduced by 44.9% (P < 0.001) after drinking 1 to 4 oz of TNJ for 1 mo. Dose-dependent analyses of aromatic DNA adduct levels showed reductions of 49.7% (P < 0.001) in the 1-oz TNJ group and 37.6% (P < 0.001) in the 4-oz TNJ group. Gender-specific analyses resulted in no significant differences in the 4-oz TNJ groups. Interestingly, the 1-oz TNJ group showed a reduction of 43.1% (P < 0.001) in females compared with 56.1% (P < 0.001) in males. The results suggest that drinking 1 to 4 oz of TNJ daily may reduce the cancer risk in heavy cigarette smokers by blocking carcinogen-DNA binding or excising DNA adducts from genomic DNA.

Who is providing and who is getting asthma patient education: an analysis of 2001 National Ambulatory Medical Care Survey data.

Patient education in asthma management is important; however, there is little known about the characteristics of patients receiving asthma education or how often primary care physicians provide it. The objective of the study was to identify the characteristics of patients receiving asthma education. It was a cross-sectional study using 2001 National Ambulatory Medical Care Survey data. The study included 1230 physicians providing office-based ambulatory medical care in the United States. Patients in the study (weighted n=11,279,952) were those diagnosed with asthma based on International Classification of Diseases, 9th Revision code receiving care from a pediatrician, internist or a family physician. Main and secondary outcome measures were asthma education ordered or provided. Multivariate analysis indicated that asthma patients receiving education were more likely to have office visits >20 min [odds ratio (OR) = 3.934], be seen for an acute reason (OR = 2.268), be seen in follow-up rather than an initial visit (OR = 1.780), live in rural rather than metropolitan areas (OR = 1.507), have public rather than private insurance (OR = 1.276) and be seen in privately owned practices (OR = 1.248). Bivariate analyses indicated that patients seeing family physicians were more likely than those seeing internists or pediatricians to receive education. Patient education was not uniformly provided. Family physicians provided more asthma education than either pediatricians or internists. Future research should investigate the quality of education provided.

Diagnosis and treatment of community-acquired pneumonia.

Patients with community-acquired pneumonia often present with cough, fever, chills, fatigue, dyspnea, rigors, and pleuritic chest pain. When a patient presents with suspected community-acquired pneumonia, the physician should first assess the need for hospitalization using a mortality prediction tool, such as the Pneumonia Severity Index, combined with clinical judgment. Consensus guidelines from several organizations recommend empiric therapy with macrolides, fluoroquinolones, or doxycycline. Patients who are hospitalized should be switched from parenteral antibiotics to oral antibiotics after their symptoms improve, they are afebrile, and they are able to tolerate oral medications. Clinical pathways are important tools to improve care and maximize cost-effectiveness in hospitalized patients.